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A Short History of Restraint Use.

“The great stumbling-block of the American superintendents is their most unfortunate and unhappy resistance to the abolition of mechanical restraint,” said British asylum superintendent John Charles Bucknill in 1876.

In the mid-19th century, after a long history of poor conditions, England started reforming its insane asylums. Cases like that of James Norris, a former seaman who spent ten years shackled to his bed with an iron harness, lead the reformers to push for the near-total abolition of restraint use. The British believed that in a well-run asylum with properly trained physicians on staff, they would rarely be necessary.

Since the first state-run mental hospital in the United States wasn’t established until 1822, Americans didn’t have the same negative history during the British reformation. Rather than seeing restraints as evidence of mistreatment, American physicians believed that restraints were a valuable tool to keep patients safe. They also believed that patients of a democratic nation were less tolerant of authority, and that the American insane were more violent than their British counterparts.

Nowadays, anything that is used to restrict a patient’s movement is a type of restraint, and can include leather or Velcro anklets and wristlets used to attach a patient to his bed, holding a patient, locking a patient in his or her room, or administering sedating chemicals. At the time, restraint was a different story.

To help American psychiatric patients regain self-control, the Quakers invented the straitjacket, which originally bound the entire body from neck to ankles. In contrast, British asylum superintendent John Conolly invented the padded seclusion room to control violent patients without mechanically restraining them. For the British, mechanical restraint was the greatest evil, and didn’t see a problem with holding patients or locking them in seclusion rooms instead.

After the Great Depression and the first and second world wars left state-run mental hospitals in America horribly overcrowded and understaffed, restraint became a necessary means of control, rather than a therapeutic tool.

In 1948, Albert Deutsch published “The Shame of the States,” exposing how bad conditions in state hospitals across the country had become. In the City Receiving Hospital in Detroit, Deutsch found that one out of every four patients was mechanically restrained during the day, rising to one out of every three patients at night.

“Never have I seen so large a proportion of mental patients subjected to such restraint,” wrote Deutsch. “Only a few were really violent or dangerous. Most of the others had been restrained, Dr. Stanton told me, because there were not nearly enough attendants or nurses to supervise the patients. Mechanical restraint was regarded as a safe and easy solution to this problem of gross overcrowding and understaffing.”

Deutsch compared the mental hospitals to the Nazi euthanasia program for the mentally ill, calling it “euthanasia by neglect.” Americans were horrified.

In 1947, after several of Deutsch’s articles and photographic essays had come out in the New York Star, President Truman signed the National Mental Health Act into law. Deutsch appeared in support of the bill, which allocated funds for mental health research, the training of psychiatrists and the establishment of mental health clinics nationwide to provide out-patient care.

Shortly afterwards, in the early 1950s, the first anti-psychotic drugs were developed and doctors suddenly trumpeted that they had found a ‘cure’ for insanity, rendering mechanical restraints and psychiatric hospitals obsolete. In 1963, President Kennedy signed the Community Mental Health Centers Act into law, dedicating funding to allow mentally ill patients to receive treatment in the community, starting the trend towards de-institutionalization.

The availability of therapeutic drugs and the closing of the state-run mental hospitals that had so embarrassed the country just a decade before was supposed to usher in a restraint-free golden age of psychiatric care. Instead, the introduction of community care created a bifurcated system, with little continuity of care between the community homes, the mental hospitals, and the emergency departments, where patients in acute psychiatric distress were now being cared for.

When it came to restraint use, just like when the British tried to eliminate restraints in the 19th century, one form of restraint was just substituted for another.

“In the last few years, the use of tranquilizers has changed the face of the problem substantially,” wrote Nina Ridenour in Mental Health in the United States in 1961. “But, even so, vigilance will be required to the end of time to make certain that hospital patients are not harmed by the improper use of restraint.”